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SK SH114 Please print or type. Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS i.Generator ID Number r 2 Page 1 of 3.Emer a :y Response Phone 4.Manifest Tracking Number WASTE MANIFEST -allklff'_i.'�.Li71 1 1 �ZIP4L,15-1 h 10OP029159 SKS 6.Generator's Name and Marling Address Generalor's Site Address(if different than mailing address) III r'edion inc loradion Inc P.S.❑ Box Gi�9 Nttnt Roger, Hoffdahl 10 1 Industrial Lr S i OCK l ON LA 9.je/t --0000 Generator's Phone: G ,'1`98ti® S-IUCi1TUN CA 952"06-3920 6 Transpate.t Company Name U.S.EPA ID Number SYSI'EMS INC TxNtllt�Jrli0612--05 7.Transporter 2 Compaw Name U.S.EPA ID Number GLf-"N tu,: _ NS ENV SVC INC. MAD039322250 S.Designated Facility Name and Site Address Cl.l. Il`I r ;)I]Hc� tiVUlfrLl�ifirPllF.L JERVICEB, IN U.S.EPA ID Number i:�.i7 S t,l,ult.vAY 71 K i v;bP.i-L , NE 69145 NED981723513 Facility's Phone: 06-235-4012 ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. f—,Type Quantity Wt.Nol. X t RO LN1c?3, WASTE Y,7-�OSENE, 3, PO :II P i1o£i: 0 Z 2. W t7 - 3. 4. 14.Specht Handling Instructions and Additions[information TSU a KP 87006712 C079 48 CS6 t 11 ERG#1 Eb' esN ENErb?l;�'raG't#9�a�-�: '3-17&kT-i:1lISK!TPI—u�ntracf retained !�y geiler� �r r_cn`kr'� or) initial trans arter to add or substitiji-e adelitional trans ot-te r ' F7_, 15. GENERATOR'SIOPFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable intemationaland national governmental regulations.If export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if i am a large quantity generator)or(b)(if I am a small quantity generator)is true. Gene d?s�Jfferor's Prnfed/Typ d Name Signature Month Day Year I_j 16.International Shipments ❑import to U.S. ❑Export from U.S. Port of entry/exit. ? Transporter signature(for exports only): Date leaving U.S.: lY 17.TransporterAcknowledgment of Receipt of Materials _ Transporter 1 PrintedtT pbd Name Signature' Month Day Year CL 2 Transporter/2 Printed Typed Name Signature Month Day Year 18.Discrepancy i8a.Discrepancy indication SpaceEl ❑ Quantity ❑Type 0 Resfdue ❑Panfal Rejection Full Rejection Manifest Reference Number. EFacilitysPhone:: ity(or Generator) U.S.EPA ID Number J_ V I W 18e.Signature ofAltamateFacility(or Gensrator) Month Day Year Q z N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 0 1. 2. 3. 4. 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a PrintedrTyped Name Signature Month Day Year EPAF0rm870022 %yr 12-17) P�gviouseditionsare obsolete. GENERATOR'S INITIAL COPY EPA `J164i;t! c21d 4461